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Represented, but the Latter, Instead Or Being Rounded Muscles ; Both Rise and Fall Are Rapid and the Line of the and Sustained, Forms a Sharp Angle

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Represented, but the Latter, Instead Or Being Rounded Muscles ; Both Rise and Fall Are Rapid and the Line of the and Sustained, Forms a Sharp Angle 1529 begun aouve at the tlllH1 1-10, and transvetsely Excended from ON THE PULSUS BISFERIENS OF AORTIC the right border of the sternum to a point nearly one inch to REGURGITATION.1 the left beyond the posirjon of the maximum Impulse. A long, soft diastolic murmur in the aortic area entirely replaced the MICHELL M.D. BY J. CLARKE, M A, CAMB., aortic second sound, aLd was conducted upwards but more M.R.C.P. LOND., distinctly downwards along the left border of the sternum, PHYSICIAN TO THE GENERAL HOSPITAL, AND LECTURER ON PRACTICAL and was audible at the apex. the first sound at the PHYSIOLOGY, UNIVERSITY BRISTOL. COLLEGE, apex was indistinct, and sometimes during his stay in hospital a systol’c murmur appealed there. No systolic SHORTLY after reading the very instructive and interest- murmur was heard at the base. The pulmonary second ing papers of Dr. Graham Steell on this subject,2 and sound was feeble. There was a little dulness at the base of the left and the liver and were both to which I here express my indebtedness, a well-marked lung, fpleen There was no and the urine did not contain of the somewhat rare of this described enlarged. dropsy .example type pulse albumen. A cardiographic tracing at this time, taken him came under own observation. This of by my variety over the seat of the maximum ventricular impulse, showed pulse is generally described as a form produced by aortic delay in the pulse wave (only an indication and not a good stenosis, but occurring much more rarely than the more tracing of the brachial pulse was obtained) ; in the ventri- cisual modification of the pulse found in this lesion-namely, cular curve the rise due to the auricle was well marked, and a the anacrotic pulse. Dr. SceeU defines the pulsus bisferiens second notch near the top of the ascending line occurs, pro- due to contraction of the as follows: "Both percussion and tidal waves are well bably commencing papillary represented, but the latter, instead or being rounded muscles ; both rise and fall are rapid and the line of the and sustained, forms a sharp angle. Moreover, the second diastolic period varies, sometimes ascending rapidly and at wave begins low and the two waves reach the same other times being straight. On Nov. 7th, by which time level, or nearly so. The dicrotic wave follows and its he had much improved and was able to be up, degree of development varies." He states that the object of the pulse was felt by the finger to give a double Lis "communication is to raise doubt as to the true nature of shock.i Fig. 1 shows well the peculiar characters of the the pul,us bisferiens being necessarily associated with aortic pulsus bisferiens ; the dicrotic wave is plairly marked, " stenosis. In his case the peculiar pulse was present in the following the tidal wave. On Nov. 14th the tracing still left radial only ; there was a double aortic murmur with systolic thrill. In a subsequent communication3 he gives the FIG. 1. results of the necropsy. Mitral stenosis was present, and the left ventricle was greatly dilated and somewhat hyper- trophied. The aortic cusps were extensively diseased, but ’from the nature of the lesions Dr. Steell concludes that "there would not be a very extreme degree of obstruction to the blood passing from the ventricle into the aorta." No explanation of the pulsus bisferiens being unilateral was dis- covered. The circumference of the aortic orifice was one inch and three-quarters. I will now relate my own case, which was under observation at different periods during several years, in which the pulsus bisferiens was present at one shows the double beat, but the percussion wave is now much period of the case in great perfection and imperfectly at greater than the tidal ; the dicrotic wave is well marked and another, and in which the post-mortem examination showed the pulse fairly full between the beats. (Fig.2.) On Nov. 21st ’the presence of free regurgitation, but no obstruction at the aortic valve. FIG. 2. A man twenty-one years of age came under observation as an out-patient at the General Hospital, Bristol, on Jan. lst, 1889, complaining of shortness of breath and palpitation. He had had syphilis eighteen months previously, but never rheu- matism or rheumatic fever. He worked at a manufactory, and his employment involved exposure to great heat from boilers and sevre muscular exertion in shifting casks weighing from 16 to 17 cwt. There was no suspicion of lead poisoning, and the illness had come on gradually without assignable cause. There was capillary pulsation and also much pulsation of the arteries. The beat of the heart was felt in the sixth apex the pulse showed more decided evidence of regurgitation, the one inch outside the The area of dulness space nipple. began artery being very empty between the beats, the rise of the at the third rib and extended from to out- above, midsternum lever during the percussion wave is higher than in previous side the line. A aortic mur- nipple long blowing, diastolic, tracings and the tidal wave smaller, both, however, being still mur was a fainter one. Both were preceded by systolic separated by a distinct notch. (Fig. 3 ) There was a distinct heard all over the cardiac area, but loudest at the base, and the former was conducted down the sternum, and also to the FIG. 3. apex. The pulse was 84, tense during the wave, and water- hammer in character. A sphygmographic tracing showed a well-marked rise due to the tidal wave and a distinct dicrotic wave ; after the administration of ten minims of tincture of digitalis three times a day for two weeks, showed tracing of pulsus bisferiens, but with tidal wave not rising very high. I did not see him again until Oct. 13tb, 1893, when he was admitted into the hospital with a history of cardiac symptoms for twelve months previously ; he had managed to do his work, however, until a week before admission. He was a very temperate man as regards alcohol, but drank tea four times a day. He was ansemio, but well nourished. There interval between the carotid and radial pulses. The tempera- Was pulsation in the arteries of the neck and in the upper and ture was, as a rule, normal, but reached from 99 5° to 99 80 F. lower extremities, and a thrill was to be felt in the subclavian on a few occasions. He went out shortly afterwards, but and innominate arteries. Capillary pulsation was noted. The was readmitted on March 16th, 1894. The pulsation in apex beat of the heart was heard in the sixth space half an the vessels was now more marked than before. The inch external to the nipple ; the maximum impulse was heard apex beat of the heart was felt in the sixth space ill the fifth space internal to the nipple. The area of dulness outside the nipple ; dulness extended above to the second rib, as far out as the right border of the sternum at 1 A paper read before the Bristol Medico-Chirurgical Society on this level, and at the fourth rib from one inch beyond - 1894. Nov... 14th.- the sternal border to half an inch the 2 medical Chronicle, vol. xviii., pp. 229 and 313 right beyond 3 Loc. cit., p. 313. 1 nipple line to the left. There was some deep seated pulsation 1530 to the right border of the sternum in the second andcomesI more sudden (straighter upstroke) and higher. Further, third intercostal spaces (dilatation of aorta). Loud diastolic cardiograms showed that there was delay in the transmis-. aortic and fainter systolic mitral murmurs were heard. The sion of the pulse wave. With regard to the question of the pulse-rate was 72. The sphygmograph showed the pulse occurrenceI of the pulsus bisferiens in aortic stenosis or in of aortic regurgitation with notch of tidal wave plainlyregurgitation, I have given three tracings from other cases, in. marked on down stroke and the dicrotic wave absent, which there were, however, no post-mortem examinations. no sign of pulsus bisferiens being present. The tracing Fig. 4 was from a man aged seventy-five years, with enlarged taken from the carotid arteries with cardiograph (record- ing tambours and drum of Rothe’s polygraph) showed a FIG. 4. distinct notch about half way up the ascending line of trace. According to Landois and Stirling4 in well-marked aortic insufficiency an anacrotic pulse wave occurs in the large vessels from the contraction of the auricle causing in the blood a wave which is at once propagated through the open mouth of the aorta into the large bloodvessels and is soon lost in the peripheral vessels. This I take to be the explana. tion of this notch in the carotid trace. After a short stay in the hospital he was relieved by rest and treatment and went to a convalescent home. He was admitted again very ill on Oct. 16th and died on the 22nd. He was too ill during this period to be disturbed by taking fresh tracings-in fact, he heart ; the apex-beat was present in the sixth space, twc. appeared to be dying on admission, but rallied a little for inches outside the nipple ; there were faint systolic, and two days, then gradually sank, and died. The aortic diastolic long, loud blowing diastolic murmurs at the right base, murmur was extremely loud, with a marked systolic murmur conducted in the usual directions.
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